Love your heart, love your brain . . . it’s simple

Heart disease and brain health go hand in hand.

By Jon Caswell

Brains are complex, but brain health, not so much. At least that is the conclusion reached by a team of clinicians tasked by the American Heart Association/ American Stroke Association with investigating brain health. The result of their investigation is the AHA/ASA Presidential Advisory Defining Optimal Brain Health in Adults published in Stroke.

Clearly, we all want to have a healthy brain. Cognitive function is an important component of aging and impacts quality of life, functional independence and risk of having to be cared for outside of one’s home. As people age, their risk of dementia rises. That is not an outcome any of us want for ourselves or our loved ones, so we all have a dog in the brain-health hunt.

Nearly 4 million Americans had dementia in 2010, which is on the rise due to an aging population and increased life expectancy. By 2030, an estimated 75 million people will have dementia worldwide, compared to 47 million today.

The first job of the task force was to define brain health in a way that could be measured easily, could be monitored and could be modified. “As we went through a process of elimination, we settled on four ideal health behaviors and three ideal health factors,” said Philip B. Gorelick, M.D., the lead author of the advisory and Neuroscience Executive Medical Director at Mercy Health Hauenstein Neurosciences in Grand Rapids, Michigan. “These seven items correlate to the American Heart Association’s Life’s Simple 7. The behaviors are nonsmoking, physical activity at usual recommended goal levels, healthy diet consistent with the current guidelines, and a body mass index of less than 25. The ideal health factors are blood pressure of less than 120 over less than 80, total cholesterol of less than 200 and a fasting blood glucose of less than 100.” The committee’s preference was that the factors be met in a “natural state,” i.e., without medications.

It may be surprising that their focus was not on cognitive outcomes like depression, happiness or dementia, but these are much harder to measure. “Those could be considered secondary outcomes, and we didn’t focus on neuropsychological testing as a screening tool to determine ideal brain health,” he said. “If you look through the literature, what you’ll find is Life’s Simple 7 factors, and the more of these factors you have present in their ideal state, the more likely you are not only to have reduction of heart attack and stroke but also to have preservation of your cognitive vitality.”

Not surprisingly, heart disease and brain health go hand in hand. In fact, many forms of heart disease are associated with cognitive impairment, cognitive decline or dementia. Atrial fibrillation is a clear example as stroke is a common result of it, and the consequent loss of brain tissue with a stroke may lead to cognitive impairment. “However, studies have shown that patients with atrial fibrillation who don’t have strokes still have cognitive impairment,” Gorelick said.

Another example is heart failure and a consequent low ejection fraction that results in poor blood flow to the brain. “That could result in some type of dysfunction of the brain based on lack of adequate blood perfusion,” he said. “Another example is people who have heart attacks and develop clots in the left ventricle. A piece or pieces of the clot can break off, shoot up into the brain and cause strokes. If those same patients have multiple strokes, they will lose key brain tissue controlling cognition and end up with cognitive impairment.”

Another type of cognitive impairment derives from “silent” strokes that occur in the smaller vessels deep in the brain. Individually, these strokes may register as only small areas affecting the brain, but those injuries can accumulate over time and cause noticeable impairment. “Oftentimes, we find evidence of small strokes on MRI scans or CT scans of the head performed for some other reason, such as headache or dizziness,” Gorelick said. “What we’ve learned is those strokes are not so silent. They actually predict that you’re at higher risk of having a clinical stroke. They also predict a higher risk of having cognitive impairment.”

Is deterioration inevitable?

Given that atherosclerosis starts in childhood for some Americans, deteriorating heart health seems inescapable. But Gorelick says that it is not, pointing out that there are certain groups of people around the world that do not get heart disease. “For example, the Tsimane tribe in South America has been studied and published about in the Lancet this year,” he said. “They have the lowest levels of coronary artery disease in the world; essentially, they don’t get atherosclerotic heart disease.”

We Americans don’t have the Tsimane’s subsistence lifestyle. However, that doesn’t mean we can’t reduce the burden of atherosclerosis and other heart disease. “There are people in the U.S. population who are free of hypertension and diabetes, high cholesterol, and who are not obese, and who don’t smoke and do engage in physical activities, and these people also tend to be less likely to go down that pathway of atherosclerosis, heart attack and stroke.”

Not only is deterioration not inevitable, it may be reversible. Gorelick points to the FINGER study from Finland. “In that trial they studied people who were coached to have more meticulous control of their cardiovascular risks, more exercise and healthier eating patterns,” he said. “It was shown that those people were more likely to improve or maintain cognitive function. This work needs to be validated by additional study, but it certainly leads us to believe that by controlling cardiovascular risk factors and practicing a healthy lifestyle, we may be able to prevent cognitive impairment or at least slow its progression in older persons.

“My suspicion is that somewhere in midlife or earlier, these changes start taking hold, and they lead us down the pathway to cognitive impairment or dementia when we become older,” he said. “It’s like a switch in the brain gets flipped and turns on this process. Whether it’s in midlife or earlier, we don’t know for sure. But we know that whether you’re in middle age or younger, practicing better lifestyle and risk factor health seems to help you maintain your heart and brain health.”

More bang for the buck

Perhaps it is human nature to do as little as possible, but that is not going to get the job done in relation to brain health. No single behavior or factor provides more benefits than another or overrides the others. “We believe that it’s the combination of healthy lifestyle and risk factor control that’s most important,” Gorelick said. “The message I don’t want people to take away is that you can exercise and then go out and have a high-fat, high-salt diet. It doesn’t work that way. You are better off trying to combine these healthy practices for lifestyle and risk factor control and not count on one of them to override the others.”

Perhaps it is human nature to do as little as possible, but that is not going to get the job done in relation to brain health.

Life is full of risks: some we can mitigate, some we can’t. According to the advisory, brain health is one we can affect. “The more of these risks you have from the health behavior and health factor standpoint, the more likely you are to have heart attack, stroke and cognitive impairment,” Gorelick said. “The fewer of these risks you have, the more likely you are to have cognitive vitality and less risk of stroke and heart attack.

“We may not only be able to prevent heart attacks and strokes, but we may be able to prevent cognitive decline and cognitive impairment and thus help people maintain their cognitive vitality,” he said. “This is really good news.”

Types of dementia . . . . . . . . . . . . . . . . . . .

Dementia is a severe loss of thinking abilities that interferes with a person’s ability to perform daily activities such as working, driving and preparing meals. Various disorders and factors contribute to the development of dementia. Neurodegenerative disorders result in a progressive and irreversible loss of neurons and brain functioning. Currently, there are no cures for these types of disorders. They include:

Alzheimer’s disease — Alzheimer’s disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out even simple tasks. In most people with the disease—those with the late-onset type—symptoms first appear in their mid-60s. Alzheimer’s disease is the most common cause of dementia among older adults. Unless the disease can be effectively treated or prevented, the number of people with it will increase significantly if current population trends continue. This is because increasing age is the most important known risk factor for Alzheimer’s disease. Estimates vary, but experts suggest that more than 5 million Americans may have Alzheimer’s.

Vascular dementia — Vascular dementia and vascular cognitive impairment (VCI) result from injuries to the vessels supplying blood to the brain, often after a stroke or series of strokes. Vascular dementia and VCI arise as a result of risk factors that similarly increase the risk for cerebrovascular disease (such as stroke), including atrial fibrillation, high blood pressure, diabetes and high cholesterol. The symptoms of vascular dementia can be similar to those of Alzheimer’s, and both conditions can occur at the same time. Symptoms of vascular dementia can begin suddenly and worsen or improve during one’s lifetime. This type of dementia is often managed with drugs to prevent strokes. The aim is to reduce the risk of additional brain damage. Interventions that address risk factors may be incorporated into the management of vascular dementia. It is considered the second most common form of dementia after Alzheimer’s.

Frontotemporal disorders — Frontotemporal disorders are the result of damage to nerve cells in the frontal and temporal lobes of the brain. As neurons in these regions die, these lobes shrink. Gradually, this damage causes difficulties in thinking and behaviors normally controlled by these lobes. Many possible symptoms can result, including unusual behaviors, emotional problems, trouble communicating, difficulty with work or difficulty with walking. Frontotemporal disorders are forms of dementia caused by a family of brain diseases known as frontotemporal lobar degeneration (FTLD). The disorders are progressive, meaning symptoms get worse over time. In the early stages, people may have just one type of symptom. As the disease progresses, other types of symptoms appear as more parts of the brain are affected. Scientists estimate that FTLD may cause up to 10 percent of all cases of dementia and is the second most common cause of dementia, after Alzheimer’s, in people younger than age 65. Roughly 60 percent of people with FTLD are 45 to 64 years old.

Lewy body dementia —Lewy body dementia (LBD) is a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain. In the healthy brain, alpha-synuclein plays a number of important roles in nerve cells in the brain, especially at synapses, where brain cells communicate with each other. In LBD, alpha-synuclein forms into clumps inside neurons, causing them to work less effectively and, eventually, to die. These deposits affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior and mood. LBD can occur alone or along with Alzheimer’s or Parkinson’s disease. It affects more than 1 million people in the United States, typically begins at age 50 and appears to affect slightly more men than women.

Mixed dementia, a combination of two or more disorders, at least one of which is dementia.

In addition, certain medical conditions can cause serious memory problems that resemble dementia. These problems should go away once the conditions are treated. These conditions include:

Side effects of certain medicines

Depression

Certain vitamin deficiencies

Drinking too much alcohol

Blood clots or tumors in the brain

Head injury, such as a concussion from a fall or accident

Thyroid, kidney, or liver problems

Sleep Apnea . . . . . . . . . . . . . . . . . . . .

Another risk to the health of our brains is sleep apnea, in which a person may experience pauses in breathing five to 30 times per hour or more during sleep. Each episode wakes the sleeper as he or she gasps for air. It prevents restful sleep and is associated with high blood pressure, arrhythmia, stroke and heart failure.

One in five adults suffers from at least mild sleep apnea, and it afflicts more men than women. The most common type is obstructive sleep apnea in which weight on the upper chest and neck contributes to blocking the flow of air.

Obstructive sleep apnea (OSA) is associated with obesity, which is also a major risk factor for heart disease and stroke. Besides obesity contributing to sleep apnea, sleep deprivation caused by sleep apnea can, in an ongoing unhealthy cycle, lead to further obesity. In OSA the upper airway closes off because the muscles that hold it open lose tone — the more weight, the more loss of tone and the more severe the sleep apnea. Each time the airway closes, there is a pause in breathing.

Another type of sleep apnea, called central sleep apnea (CSA), is far less prevalent. In CSA the brain doesn’t send regular signals to the diaphragm to contract and expand. There is limited snoring with CSA, and it has been associated with brainstem stroke because the brainstem is where the impulse to breathe comes from.

High blood pressure is a major risk factor for heart disease and stroke. When your blood pressure stays within healthy ranges, you reduce the strain on your heart, arteries and kidneys, which keeps you healthier longer.

High cholesterol contributes to plaque, which can clog arteries and lead to heart disease and stroke. When you control your cholesterol, you are giving your arteries their best chance to remain clear of blockages.

When you shed extra fat and unnecessary pounds, you reduce the burden on your heart, lungs, blood vessels and skeleton. You give yourself the gift of active living, you lower your blood pressure and you help yourself feel better, too.

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